Breast Surgery – Breast Reconstruction

What is Reconstructive Breast Surgery?

Breast reconstruction offers hope for a woman losing her breast to cancer. Reconstruction can often be performed at the same time as the mastectomy, beginning the process of restoration and healing. Depending on health conditions, however, a mastectomy patient may have to wait before undergoing reconstructive surgery. Whether Breast Reconstruction is done immediately or on a delayed basis, this surgery holds much promise that the post-operative breast can match the natural breast again.

The Beast Reconstruction Surgery Procedure

When reconstructive surgery is performed simultaneously with the mastectomy, Dr. Cambre will discuss your surgical options, as well as the risks and alternatives to each option. This may include the two-stage approach, inserting a tissue expander at the first operation, followed months later by replacement of the expander with a permanent silicone breast implant, or the use of your own tissues to reconstruct the breast mound in one stage. Dr. Cambre will work with your oncologist and general surgeon to ensure the best possible conditions for reconstruction.

Breast reconstruction usually involves more than one operation, and secondary follow up procedures may be performed on an outpatient basis. Follow-up procedures may only require local anesthesia, and often involve reconstruction to recreate the nipple and areola, or scar revisions. Sometimes surgery is performed on the natural breast to match the reconstructed breast; such procedures include Mastopexy (breast lift), Breast Reduction, or Breast Augmentation.

Skin Expander with Breast Implant

This is the simplest of breast reconstructions, with the shortest recovery period. This is the favored procedure for persons who have heath problems or contradictions to surgery that is more extensive.

Breast reconstruction using tissue expanders is performed in two stages. In the first stage, a tissue expander is placed under the skin and muscles of the chest wall at the same operation as the mastectomy procedure (immediate reconstruction). In other circumstances, the expander is placed many months or years after the mastectomy procedure (delayed reconstruction). After healing of the incisions, saline is added on a weekly basis to the expander. As the expander inflates, the skin envelope is gradually stretched and enlarged.

When the skin has been sufficiently stretched, the tissue expander is removed, and is replaced by a permanent breast implant in the second stage procedure. Nipple reconstruction, if desired, is performed as a separate procedure.

Advantages: Simplest surgery and shortest recovery from surgery.

Disadvantages: Multiple trips to the office over several weeks or months to undergo expansion. Capsule formation or poor cosmetic result due to thin skin.

Possible Complications:

• Loss of breast skin requiring removal of implant. If you have undergone radiation or if you are a smoker, this procedure is not advisable as you are at increased risk for skin loss.
• Noticeable outlines of the implant due to capsule formation or thin breast skin
• Hard texture due to capsule formation
• Inadequate symmetry or implant position as compared with the remaining breast

Latissimus Dorsi Myocutaneous Flap

This surgery involves moving the latissimus dorsi muscle and overlying skin from the back, tunneling it to the chest to create a new breast mound. The incision is usually made along the bra line so the scar will be concealed.

Blood transfusions are not usually required. A breast implant is often placed under the flap if necessary to balance a difference in size. Nipple reconstruction is done later.

Advantages: This is a very reliable procedure, which provides good tissue coverage for an implant. The chances of capsule formation around the implant are reduced.

Disadvantages: Scar across the back. There may be decreased strength in the back due to muscle loss (usually minimal). Capsule formation may occur and result in the need for additional surgery.

Possible Complications:

Circulation problems with the flap Formation of capsule around the implant Symptoms from loss of shoulder muscle, such as decreased strength Unsightly scar on the back, not hidden by clothing Collection of fluid (seroma) under incision requiring needle aspiration

Rectus Abdominus Myocutaneous Flap

This is the most complicated type of breast reconstructive procedure, involving about 4 – 5 hours of surgery. The procedure can be done either as a “pedicle” flap, or as a “free” flap. In the pedicle flap operation, one of the rectus abdominus muscles along with its’ blood supply is tunneled along with the overlying skin up to the chest. In the “free” or microsurgical procedure, a portion of the rectus abdominus muscle with its overlying skin is removed from the lower abdomen. The artery and vein are then surgically re-attached under the operating microscope to an artery and vein on the chest wall near the mastectomy site. In both procedures, the breast mound is then created to match the opposite site. A blood transfusion may be required. You may donate your own blood before surgery to be re-infused during the surgery.

Breast implants are not usually required. The tissue is generally adequate to match the size of the opposing breast. If the opposite breast is large or pendulous, it can be decreased in size by a simultaneous Breast Reduction. Patients wishing to have this procedure must stop smoking six weeks prior, and six weeks following surgery. Failure to comply may result in death of the flap. A synthetic mesh is placed over the area of the abdominal wall where the muscle is removed. This strengthens the abdominal wall and minimizes the chance of hernia formation. Nipple reconstruction is done as a second procedure. Some contouring of the new breast mound may be necessary at the same time.

Advantages: This provides the most natural looking breast reconstruction with the added benefit of a “Tummy Tuck”. No implant is needed so capsule formation is not a risk. The scar is easily hidden with clothing.

Disadvantages: There is a risk of herniation of the bowel resulting from moving the rectus abdominus muscle. Abdominal strength is diminished. This is the longest procedure and has the greatest risk for complications, and may require a blood transfusion.

Possible Complications:

Inadequate tissue requiring the use of a breast implant Poor circulation to the flap resulting in tissue loss Weakness or herniation of the abdominal wall Collection of fluid (seroma) under the skin requiring needle aspiration Infection, in particular of the mesh requiring surgery for removal

Nipple Reconstruction

The reconstruction of a nipple adds a very pleasing final touch to the breast. This is a simple outpatient procedure that may be done with local anesthesia. The goal of the surgery is to create a nipple that has the appearance of the nipple of the opposite breast. To reconstruct the nipple, a local flap of skin is usually taken from the breast flap. To reconstruct the areola, skin may be taken from the inner part of the upper thigh or from behind the ear. These areas tend to have a darker pigment, which will provide a better contrast to the breast tissue. As a second procedure, the healed nipple can be tattooed to improve the color match of the opposite breast.

Possible Complications:

• Excessive scarring
• Shrinkage of the projecting part of the nipple
• Infection of the donor site or the newly created nipple
• Blood clot under the nipple, which may result in loss of all or part of the new nipple

FAQ’s

Q: How will I look / feel after the surgery?
A: Reconstruction of the breast following mastectomy is a very rewarding procedure to both the patient and the surgeon. Many women describe a feeling of once again being whole. There are many written materials available regarding breast reconstruction. There are support groups available where one can meet women who have gone through these procedures. Ask us for references, books, and support groups in your area. Take advantage of these invaluable resources.